INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to document monthly fire drills from March 2020 through March 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure monthly fire drills resume at vacated satellite sites on a monthly basis starting April 2021. Facility Director or assigned clinician will drive to physical satellite location monthly in order to conduct monthly fire drill. Live drill will be recorded on Fire Drill Log. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of two records reviewed on April 14, 2020.
Employee # 1 was hired on August 29, 2018. No annual performance evaluations were documented in employee record # 1.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure all performance evaluations are conducted on a yearly basis. Facility Director will conduct current employee annual evaluations of clinicians in February 2022, June 2021, and December 2021. Executive Director will complete Facility Director evaluation in August 2021. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven records reviewed on April 14, 2021.
The client's name and diagnosis were released to the insurance company, during the intake process, to authorize drug and alcohol treatment services in the following client records.
Client # 1 was admitted September 21, 2020 and discharged November 24, 2020.
Client # 2 was admitted December 3, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency shall review all currently active charts and obtain written consent for these charts. Checks shall be tracked on newly updated Consent Summary Spreadsheet. Facility Director shall ensure all future first patient appointments by clinician occur physically on grounds. Prior to meeting with clinician, perspective patient will engage in registration process with support staff as written consent/releases of information are facilitated in this process. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility did document a consent to release information form but failed to include the dated signature of the client in three of seven records reviewed on April 14, 2021.
Consents for the following records were documented during the intake process.
Client # 1 was admitted September 21, 2020 and discharged November 24, 2020. Consents for a treatment provider and insurance company did not include the dated signature of the client.
Client # 2 was admitted December 3, 2020. Consents for a family member and insurance company did not include the dated signature of the client.
Client # 4 was admitted September 2, 2020. A consent for parole did not include the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency shall review all currently active patient charts and obtain written consent for these active charts. Agency shall utilize process of visual inspection of consents at time of facilitation to ensure consents are both signed and dated. In the event a paper release of information needs to be uploaded to the electronic medical record this documentation will be visually inspected and will not be uploaded until the client manually signs and manually dates paper(non-electronic) release of information. No correspondence will be sent to outside providers / entities until written consent has been obtained. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan review and update at least every sixty days in four of six records reviewed on April 14, 2021.
Client # 3 was admitted November 30, 2020. The individual treatment plan was documented November 30, 2020. Treatment plan updates were not documented until February 11, 2021 and April 13, 2021.
Client # 4 was admitted September 2, 2020. The individual treatment plan was documented September 29, 2020. Treatment plan updates were not documented until January 25, 2021 and March 25, 2021
Client # 6 was admitted December 5, 2019 and discharged June 4, 2020. The individual treatment plan was documented February 13, 2021. A treatment plan update was not documented until April 23, 2021.
Client # 7 was admitted December 26, 2019 and discharged April 20, 2020. The individual treatment plan was documented February 13, 2021. No treatment plan update was documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure these results are shared and processed with clinician of satellite site. Use of treatment plan update tracking sheet will be utilized by clinician and checked by Facility Director on a weekly basis. Treatment plan updates for Outpatient patients will be documented at least once every 60 days. Patients receiving Intensive Outpatient will have treatment plan updates documented at least once every 30 days. |